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Anesthesia Coding Alert

Report Invasive Line Placements With These 3 Simple Steps

Published on Tue Jul 01, 2003

If you think Swan-Ganz, A-line and central venous catheter (CVP) placements are always included in the global anesthesia fee, think again. Follow these guidelines to code your anesthesiologist's line placements as separate services and boost your bottom line.

Step 1: Match the Right Codes With CVP, A-Line and Swan-Ganz Services

The correct line placement codes depend on the type of line used and other factors. For example, to choose the correct codes for lines placed to monitor central venous pressure, you have to know two things: the patient's age and the approach used to place the line. Your options include:

  • 36488* Placement of central venous catheter (subclavian, jugular, or other vein) (e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy); percutaneous, age 2 years or under
  • 36489* percutaneous, over age 2
  • 36490* cutdown, age 2 years or under
  • 36491* cutdown, over age 2.

    To code arterial lines (also called A-lines), report 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous). These lines measure arterial blood pressure and provide easy access for drawing blood to study what gases are present, says Kelly Dennis, CPC, EFPM, owner of the anesthesia consulting firm Perfect Office Solutions in Leesburg, Fla. (Code 36625, cutdown, represents A-line insertion when the physician uses a cutdown approach, but Dennis says this code is rarely used.)

    As for Swan-Ganz lines, you will need to report the surgical service code CPT 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes). Anesthesiologists use Swan-Ganz catheters to obtain diagnostic information such as cardiac output, left ventricular filling pressure, and pulmonary and systemic vascular resistance, and to continually monitor heart function in critically ill patients.
    Invasive lines are coded as flat-fee or surgery services, which is why you report these codes instead of anesthesia codes. You also do not report anesthesia time, says Cindy Smith, CPC, an anesthesia coder with Professional Healthcare Billing Services in Charleston, W.V. If an invasive line is placed after the patient is anesthetized, however, you don't subtract the time spent placing the line from the total anesthesia time for the procedure you just add it as a separate service in addition to the procedure's anesthesia and time units. Some carriers' policies may vary on how to code a line placed after the physician administers the anesthesia, so check with your carrier when deciding how you should report the service.

    Multiple-surgery rules do not apply to these types of line insertions, so the anesthesiologist should receive full reimbursement for each line that is placed and documented. This also means that you do not append modifier -51 (Multiple procedures) when coding for multiple lines.
     
    In contrast to these invasive lines, Dennis says the standard forms of monitoring during surgical cases (such as pulse oximetry, ECG, temperature, blood pressure, capnography and mass spectrometry) are not generally reported separately. Bispectral index (BIS) monitoring is also considered routine and is not usually separately reimbursable. But Dennis has heard of BIS monitoring being separately reimbursed because it was stipulated in a carrier's contract.
     
    The bottom line? Although it's highly unusual for carriers not to reimburse for invasive lines, always know the carrier's policy. "If you're dealing with a managed-care carrier that has bundled the lines with procedures, you might want to consider this in your contract negotiations," Smith says.

    Step 2: Document Your Way to Correct Payment

    Thorough documentation will help support separately coded line placements and improve your chances for additional reimbursement. Be sure you've included the answers to these questions in your documentation if you're submitting a claim that codes invasive line placements separately:

     
  • Who placed the line? "In most cases, the anesthesiologist must place the line personally rather than just be present during the placement if you're going to bill for the line," Dennis says. However, some states allow CRNAs to bill for line placements. Check whether the hospital or malpractice carrier allows CRNAs to provide the service before you bill for it. "If the record doesn't clearly document who placed the line, you shouldn't bill for it. If you were ever audited and couldn't substantiate the charges, they would be questionable," Dennis adds.
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  • When was the line placed? Some carriers have placement-time requirements for separately reporting lines which means you must clearly state in the documentation whether the lines were placed pre-anesthesia, after the patient was anesthetized or post- anesthesia. Some carriers even specify how this should be documented. For example, Blue Cross/ Blue Shield of Alabama's policy states that "time involved in arterial line insertion should be clearly documented in the narrative section of the anesthesia record." If the line is placed while the patient is in the pre-op holding area, you only bill for the placement (no associated time units). If it's placed in the OR after induction, you can bill for time as well as the line because the anesthesiologist is already monitoring the patient.
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  • Have you checked your group's guidelines? Many practices adopt their own guidelines for when line placements are separately billable to keep their claims consistent. For example, one group might bill for lines placed prior to anesthesia induction and the procedure's anesthesia start time; another group might only bill for lines placed in the OR after induction. Know what your group's policy is so you can code accordingly.
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  • What size needle was used? This is basic information from the anesthesiologist's perspective, but documenting the needle size shows that the procedure was performed and that it should be reimbursed. Physicians use different needles for different types of placements, and normally use smaller gauges for children. Having this information can help you code more accurately.
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  • Do you need modifier -59? Know whether the carrier requires modifier -59 (Distinct procedural service) to document that the line placements were separate from the procedure's anesthesia. "The -59 modifier is meant to release the code from CCI edits that prevent line placements being billed with an anesthesia code, which is not usually the case," Dennis says. "Michigan, however, requires that you include modifier -59 with the line codes, but other states such as Florida don't."
     
    Smith's group does not use modifier -59 for any carriers, but has no reimbursement problems. When in doubt, check with the carrier to be sure of local guidelines. Reporting modifier -59 to a carrier that doesn't require it probably won't affect your reimbursement, but omitting -59 when it is required will lead to denials.
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  • Do your diagnosis codes justify additional lines? Most coders expect to see unusual monitoring (i.e., additional lines) for heart or thoracic surgery cases, patients with aneurysms, or other high-risk procedures or special circumstances. Diagnosis codes such as 441.4 (Abdominal aneurysm without mention of rupture) or 433.11 (Occlusion and stenosis of precerebral arteries; carotid artery; with cerebral infarction) can help justify the use of additional monitoring lines. But the anesthesiologist can place extra lines during any case due to events during the procedure. For example, Smith says, the physician may insert a CVP line if the patient loses lots of blood or fluids during surgery. The line can be used to rapidly replenish blood or fluid volume or to give medications that are most safely and effectively administered directly into the central venous circulation.
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  • Are the Swan-Ganz and CVP lines documented and necessary? The anesthesiologist sometimes uses a CVP port to thread the Swan-Ganz catheter, which means you can only bill for the Swan-Ganz (with 93503). But you can bill for both if the record clearly documents two separate lines and shows that both were medically necessary (such as using one line to measure cardiovascular function and the other to administer fluids or medications).
    • Step 3: Educate Everyone Involved in the Process

    Smith and Dennis agree that educating staff on both sides of the process can help increase your chances for line placement reimbursement. "One of the biggest challenges from the office perspective is educating physicians to clearly document everything," Dennis says. "But you also need to teach the office staff what things to look for on an anesthesia record to support coding the lines separately."
     
    Even if the necessary details are abstracted from the record, the carrier can still deny reimbursement if you report the wrong type of service (TOS) for the procedure.
     
    "Do not report line placements as TOS '7' (anesthesia), because they'll be denied," Dennis says. "The lines should be reported as TOS '2' (surgery) instead. Carriers will pay for it as TOS '1' (medical care), but the ASA says that TOS '2' describes the service more accurately since line placement is more of a 'procedural service' that is closer to surgery than medicine."
     
    The American Society of Anesthesiologists outlines its position on invasive monitoring procedures on its Web site. Log on to www.asahq.org and search the Publications and Services area for more information.

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